Provider Demographics
NPI:1902898182
Name:BALLARD, ROBERT BLAKESLEE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BLAKESLEE
Last Name:BALLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E MILESTONE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6701
Mailing Address - Country:US
Mailing Address - Phone:920-731-8289
Mailing Address - Fax:920-832-0444
Practice Address - Street 1:2000 E MILESTONE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6701
Practice Address - Country:US
Practice Address - Phone:920-731-8289
Practice Address - Fax:920-832-0444
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41244 020208600000X
GA421692086S0127X
LA126052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30094300Medicaid
H04226Medicare UPIN
WI30094300Medicaid